Fluoride & Tooth Decay: Topical vs. Systemic Effect

F.A.N. | June 2012 | By Michael Connett

When water fluoridation first began in the 1940s, dentists believed that fluoride’s main benefit to teeth came from being swallowed during the tooth-forming years. This belief that fluoride’s primary benefit was “systemic” and “pre-eruptive.” A “systemic” benefit is one that comes from ingesting fluoride, and a “pre-eruptive” benefit is one that occurs by swallowing fluoride before the teeth erupt into the mouth. The premise underlying this belief was that, since ingesting fluoride increased the fluoride content of the teeth, the teeth would be more resistant to decay for life.

Although this “systemic” paradigm was the premise that launched water fluoridation and fluoride supplementation programs, it has now been discarded by the dental research community. Today, as noted by the following studies, the overwhelming consensus by dental researchers is that fluoride’s primary effect is topical, not systemic, and that this topical effect occurs after the teeth have erupted into the mouth (i.e., post-eruptive), not before. There is no need, therefore, to swallow fluoride, especially during infancy and early childhood. As the Centers for Disease Control (CDC) stated in 1999 “fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children.” The National Research Council has concurred, stating in 2006 that “the major anticaries benefit of fluoride is topical and not systemic.”

For a discussion on how fluoride works topically, and how scientists came to disprove the systemic theory, click here.

Excerpts from the Scientific Literature

“it is widely recognized that the mechanism of action of F for caries control occurs essentially through its topical contact with the teeth. In other words, it is not necessary to ingest F to have F protection against caries.”
SOURCE: Charone S, et al. (2012). Lack of a significant relationship between toenail fluoride concentrations and caries prevalence. Fluoride 45:133-37.

“Fluoride is most effective when used topically, after the teeth have erupted.”
SOURCE: Cheng KK, et al. (2007). Adding fluoride to water supplies. British Medical Journal 335(7622):699-702.

“the major anticaries benefit of fluoride is topical and not systemic.”
SOURCE: National Research Council. (2006). Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. National Academies Press, Washington D.C. p 16.

“Since the current scientific thought is that the cariostatic activity of fluoride is mainly due to its topical effects, the need to provide systemic fluoride supplementation for caries prevention is questionable.”
SOURCE: European Commission. (2005). The Safety of Fluorine Compounds in Oral Hygiene Products for Children Under the Age of 6 Years. European Commission, Health & Consumer Protection Directorate-General, Scientific Committee on Consumer Products, September 20.

“When it was thought that fluoride had to be present during tooth mineralisation to ‘improve’ the biological apatite and the ‘caries resistance’ of the teeth, systemic fluoride administration was necessary for maximum benefit. Caries reduction therefore had to be balanced against increasing dental fluorosis. The ‘caries resistance’ concept was shown to be erroneous 25 years ago, but the new paradigm is not yet fully adopted in public health dentistry, so we still await real breakthroughs in more effective use of fluorides for caries prevention.”
SOURCE: Fejerskov O. (2004). Changing paradigms in concepts on dental caries: consequences for oral health care. Caries Research 38: 182-91.

“Current evidence strongly suggests that fluorides work primarily by topical means through direct action on the teeth and dental plaque. Thus ingestion of fluoride is not essential for caries prevention.”
SOURCE: Warren JJ, Levy SM. (2003). Current and future role of fluoride in nutrition. Dental Clinics of North America 47: 225-43.

“[T]he majority of benefit from fluoride is now believed to be from its topical, rather than systemic, effects.”
SOURCE: Brothwell D, Limeback H. (2003). Breastfeeding is protective against dental fluorosis in a nonfluoridated rural area of Ontario, Canada. Journal of Human Lactation 19: 386-90.

“For a long time, the systemic effect of fluoride was regarded to be most important, resulting in recommendations to use fluoride supplements such as tablets or drops. However, there is increasing evidence that the local effect of fluoride at the surface of the erupted teeth is by far more important.”
SOURCE: Zimmer S, et al. (2003). Recommendations for the Use of Fluoride in Caries Prevention. Oral Health & Preventive Dentistry 1: 45-51.

“By 1981, it was therefore possible to propose a paradigm shift concerning the cariostatic mechanisms of fluorides in which it was argued that the predominant, if not the entire, explanation for how fluoride controls caries lesion development lies in its topical effect on de- and remineralization processes taking place at the interface between the tooth surface and the oral fluids. This concept has gained wide acceptance… With today’s knowledge about the mechanisms of fluoride action, it is important to appreciate that, as fluoride exerts its predominant effect… at the tooth/oral fluid interface, it is possible for maximum caries protection to be obtained without the ingestion of fluorides to any significant extent.”
SOURCE: Aoba T, Fejerskov O. (2002). Dental fluorosis: chemistry and biology. Critical Review of Oral Biology and Medicine 13: 155-70.

“[F]luoride’s predominant effect is posteruptive and topical.”
SOURCE: Centers for Disease Control and Prevention. (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. Morbidity and Mortality Weekly Report 50(RR14): 1-42.

“Fluoride, the key agent in battling caries, works primarily via topical mechanisms: inhibition of demineralization, enhancement of remineralization, and inhibition of bacterial enzymes.”
SOURCE: Featherstone, JDB. (2000). The Science and Practice of Caries Prevention. Journal of the American Dental Association 131: 887-899.

“Current evidence suggests that the predominant beneficial effects of fluoride occur locally at the tooth surface, and that systemic (preeruptive) effects are of much less importance.”
SOURCE: Fomon, SJ; Ekstrand, J; Ziegler, E. (2000). Fluoride Intake and Prevalence of Dental Fluorosis: Trends in Fluoride Intake with Special Attention to Infants. Journal of Public Health Dentistry 60: 131-9.

“Fluoride supplementation regimens suffer from several shortcomings, the first of which may be their derivation from a time when the major effect of fluoride was thought to be systemic. Although evidence that fluoride exerts its effects mainly through topical contact is great, supplementation schemes still focus on the ingestion of fluoride.”
SOURCE: Adair SM. (1999). Overview of the history and current status of fluoride supplementation schedules. Journal of Public Health Dentistry 1999 59:252-8.

“The case is essentially a risk-benefit issue – fluoride has little pre-eruptive impact on caries prevention, but presents a clear risk of fluorosis.”
SOURCE: Burt BA. (1999). The case for eliminating the use of dietary fluoride supplements for young children. Journal of Public Health Dentistry 59: 260-274.

“Until recently the major caries-inhibitory effect of fluoride was thought to be due to its incorporation in tooth mineral during the development of the tooth prior to eruption…There is now overwhelming evidence that the primary caries-preventive mechanisms of action of fluoride are post-eruptive through ‘topical’ effects for both children and adults.”
SOURCE: Featherstone JDB. (1999) Prevention and Reversal of Dental Caries: Role of Low Level Fluoride. Community Dentistry & Oral Epidemiology 27: 31-40.

“[L]aboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children.”
SOURCE: Centers for Disease Control and Prevention. (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. Morbidity and Mortality Weekly Report 48: 933-940.

“[R]esearchers are discovering that the topical effects of fluoride are likely to mask any benefits that ingesting fluoride might have… This has obvious implications for the use of systemic fluorides to prevent dental caries.”
SOURCE: Limeback, H. (1999). A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any caries benefit from swallowing fluoride? Community Dentistry and Oral Epidemiology 27: 62-71.

“Although it was initially thought that the main mode of action of fluoride was through its incorporation into enamel, thereby reducing the solubility of the enamel, this pre-eruptive effect is likely to be minor. The evidence for a post-eruptive effect, particularly its role in inhibiting demineralization and promoting remineralization, is much stronger.”
SOURCE: Locker D. (1999). Benefits and Risks of Water Fluoridation. An Update of the 1996 Federal-Provincial Sub-committee Report. Prepared for Ontario Ministry of Health and Long Term Care.

“Recent research on the mechanism of action of fluoride in reducing the prevalence of dental caries (tooth decay) in humans shows that fluoride acts topically (at the surface of the teeth) and that there is neglible benefit in ingesting it.”
SOURCE: Diesendorf, M. et al. (1997). New Evidence on Fluoridation. Australian and New Zealand Journal of Public Health 21 : 187-190.

“On the basis of the belief that an adequate intake of fluoride in early life is protective against caries in later life, fluoride supplements are recommended for infants and children living in areas in which the fluoride content of the drinking water is low. However, critical reviews of the evidence have led to the conclusion that the effect of fluoride in decreasing the prevalence and severity of dental caries is not primarily systemic but exerted locally within the oral cavity. Because fluoride supplements are quickly cleared from the mouth, the possibility must be considered that they may contribute to enamel fluorosis, which is unquestionably a systemic effect, while providing relatively little protection against dental caries.”
SOURCE: Ekstrand J, et al. (1994). Fluoride pharmacokinetics in infancy. Pediatric Research 35:157–163.

“I have argued in this paper that desirable effects of systemically administered fluoride are quire minimal or perhaps even absent altogether.”
SOURCE: Leverett DH. (1991). Appropriate uses of systemic fluoride: considerations for the ’90s. Journal of Public Health Dentistry 51: 42-7.

“It, therefore, becomes evident that a shift in thinking has taken place in terms of the mode of action of fluorides. Greater emphasis is now placed on topical rather than on systemic mechanisms…”
SOURCE: Wefel JS. (1990). Effects of fluoride on caries development and progression using intra-oral models. Journal of Dental Research 69(Spec No):626-33;

“[E]vidence has continued to accumulate to support the hypothesis that the anti-caries mechanism of fluoride is mainly a topical one.”
SOURCE: Carlos JP. (1983) Comments on Fluoride. Journal of Pedodontics Winter. 135-136.

“Until recently most caries preventive programs using fluoride have aimed at incorporating fluoride into the dental enamel. The relative role of enamel fluoride in caries prevention is now increasingly questioned, and based on rat experiments and reevaluation of human clinical data, it appears to be of minor importance… [A]ny method which places particular emphasis on incorporation of bound fluoride into dental enamel during formation may be of limited importance.”
SOURCE: Fejerskov O, Thylstrup A, Larsen MJ. (1981). Rational Use of Fluorides in Caries Prevention: A Concept based on Possible Cariostatic Mechanisms. Acta Odontologica Scandinavica 39: 241-249.